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March/April 2014

Volume 111, Number 2

Taking a closer look at health care costs

Award-winning publication of the Colorado Medical Society


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Colorado Medicine for March/April 2014


contents Mar/Apr 2014, Volume 111, Number 2

Features. . . 10

Strategic plan update–The CMS Board of Directors began the process of revising the strategic plan at a retreat in January.

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Legislative update–Halfway through the legislative session, Colorado Medicine checks in on the top bills being followed by the Council on Legislation.

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AMA National Advocacy Conference–CMS physicians lobbied Capitol Hill in early March and made great gains for medicine on SGR repeal and the Clean Claims Task Force.

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Health care exchange update–The 90-day grace period allowed under the health care law could cause a billing headache for physicians starting in March.

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Prescription drug abuse–A new CMS committee starts work guiding society policy and action surrounding the effort to reduce prescription drug abuse.

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Medical marijuana–Larry Wolk, MD, director of the Colorado Department of Public Health and Environment, discusses medical marijuana and physician responsibilities.

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Be aware or beware–Physician contracts with hospitals need to be carefully negotiated. CMS members have access to discounted and flat-fee negotiaton/review services.

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Final Word–Alan Kimura, MD, MPH, discusses how physicians can impact costs while still making sound clinical decisions, and how incentives could encourage this practice.

Cover story

Colorado Medicine sat down for an exclusive interview with journalist Stephen Brill, whose special report in the March 2013 issue of TIME magazine, “Bitter Pill: Why Medical Bills Are Killing Us,” investigated hospital billing practices and why U.S. health care spending is out of control. Our Q & A with Brill is a continuation of our series on health care costs in Colorado. Read more on page 6.

Inside CMS 5 28 31 34 36 38 39

Executive Office Update Dimensions of Wellness Survey Results Spring Conference ICD-10 Update Clean Claims Task Force COPIC Comment AMA Ambassador Program

Departments 40 45

Medical News Classified Advertising

Colorado Medicine for March/April 2014

Editor’s note: Articles appearing in Colorado Medicine without a byline represent the collaborative work of CMS leadership and staff.

COVER CREDIT: From TIME Magazine, March 4, © 2013 Time Inc. Used under license.

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C OLOR A D O M EDICA L S O CI ET Y 7351 Lowry Boulevard, Suite 110 • Denver, Colorado 80230-6902 (720) 859-1001 • (800) 654-5653 • fax (720) 859-7509 • www.cms.org

OFFICERS, BOARD MEMBERS, AMA DELEGATES, and CONNECTION

2013/2014 Officers John L. Bender, MD, FAAFP President Tamaan Osbourne-Roberts, MD President-elect Kay D. Lozano, MD Treasurer M. Robert Yakely, MD Speaker of the House Brigitta J. Robinson, MD Vice-speaker of the House Alfred D. Gilchrist Chief Executive Officer Jan M. Kief, MD Immediate Past President

Board of Directors Charles Breaux Jr., MD Leslie Capin, MD Joel Dickerman, DO Naomi Fieman, MD Carolyn Francavilla, MD T. Casey Gallagher, MD Jan Gillespie, MD Johnny Johnson, MD Richard Lamb, MD Lucy Loomis, MD Randy Marsh, MD Gary Mohr, MD Christine Nevin-Woods, DO Edward Norman, MD Lynn Parry, MD Daniel Perlman, MD Scott Replogle, MD Floyd Russak, MD Ranee Shenoi, MD Stephen Sherick, MD Joshua Tartakoff, MS Theodore Timothy, MS Michael Welch, DO

Jennifer Wiler, MD Allison Wood, MS Harold “Hap” Young, MD Lena Young, MS AMA Delegates A. “Lee” Morgan, MD M. Ray Painter Jr., MD Lynn Parry, MD Brigitta J. Robinson, MD AMA Immediate Past President Jeremy Lazarus, MD AMA Alternate Delegates David Downs, MD Jan Kief, MD Mark Laitos, MD Tamaan Osbourne-Roberts, MD CMS Connection Mary Rice, President

COLORADO MEDICAL SOCIETY STAFF Executive Office

Alfred Gilchrist, Chief Executive Officer, Alfred_Gilchrist@cms.org Dean Holzkamp, Chief Operating Officer, Dean_Holzkamp@cms.org Dianna Mellott-Yost, Director, Professional Services, Dianna_Mellott-Yost@cms.org Tom Wilson, Manager, Accounting, Tom_Wilson@cms.org

Division of Communications and Member Benefits

Division of Health Care Financing

Marilyn Rissmiller, Senior Director, Marilyn_Rissmiller@cms.org

Division of Information Technology/Membership Tim Roberts, Senior Director, Tim_Roberts@cms.org Tim Yanetta, Coordinator, Tim_Yanetta@cms.org

Brad Pierson, Art Director/ Manager, Communications, Brad_Pierson@cms.org Mike Campo, Director, Business Development & Member Benefits, Mike_Campo@cms.org

Division of Government Relations

Division of Health Care Policy

Colorado Medical Society Foundation Colorado Medical Society Education Foundation

Chet Seward, Senior Director, Chet_Seward@cms.org JoAnne Wojak, Director, Continuing Medical Education, JoAnne_Wojak@cms.org

Susan Koontz, JD, General Counsel, Senior Director, Susan_Koontz@cms.org Angie Baker, Executive Legal Assistant, Angie_Baker@cms.org

Mike Campo, Staff Support, Mike_Campo@cms.org

COLORADO MEDICINE (ISSN-0199-7343) is published bimonthly as the official journal of the Colorado Medical Society, 7351 Lowry Boulevard, Suite 110, Denver, CO 80230-6902. Telephone (720) 859-1001 Outside Denver area, call 1-800-654-5653. Periodicals postage paid at Denver, Colorado, and at additional mailing offices. POSTMASTER, send address changes to COLORADO MEDICINE, P. O. Box 17550, Denver, CO 80217-0550. Address all correspondence relating to subscriptions, advertising or address changes, manuscripts, organizational and other news items regarding the editorial content to the editorial and business office. Subscriptions are available for $36 per year, paid in advance. COLORADO MEDICINE magazine is the official journal of the Colorado Medical Society, and as such is also authorized to carry general advertising. COLORADO MEDICINE is copyrighted 2006 by the Colorado Medical Society. All material subject to this copyright appearing in COLORADO MEDICINE may be photocopied for the non-commercial purpose of education and scientific advancement. Publication of any advertisement in COLORADO MEDICINE does not imply an endorsement or sponsorship by the Colorado Medical Society of the product or service advertised. Published articles represent the opinions of the authors and do not necessarily reflect the official policy of the Colorado Medical Society unless clearly specified.

Alfred Gilchrist, Executive Editor; Dean Holzkamp, Managing Editor; Brad Pierson, Art Director, Assistant Editor; Chet Seward, Assistant Editor. Printed by Spectro Printing, Denver, Colorado

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Colorado Medicine for March/April 2014


Inside CMS

executive office update Alfred Gilchrist, Chief Executive Officer Colorado Medical Society

Health care cost containment plot thickens The recent revelation that Colorado's mountain resort counties incurred the highest health insurance exchange rates in the country has accelerated an already revved up policy debate over the causes and effects of health care costs. Gov. John Hickenlooper has directed Insurance Commissioner Marguerite Salazar to conduct a study on insurance rates, which will lead to further debate over regional rating methods and also likely expose its complex epidemiology. Meanwhile Garfield County has announced their intent to sue the state for being lumped into the higher cost resort counties. At the same time, Senator-physician Irene Aguilar convened a group of leaders to float the idea of legislation to create a Blue Ribbon Commission on Health Care Costs. It would be modeled after the highly regarded SB208 Commission that produced a prescient pre-Accountable Care Act set of health system reform recommendations in 2008. As in preceding policy development consensus processes, we were eager to participate and contribute to this effort. Analyzing responses to the proposal, the senator recognized that stakeholder discussions on health care costs will not be easy, and adroitly tacked to the establishment and maintenance of an on-going forum, as opposed to a one-shot, time-limited, high-profile commission. Stakeholders understood and appreciated her point; a forum that builds trust and rapport among the appointees will be more likely to produce consensus outcomes. Legislative details of such a forum are now under discussion. This is not by any measure the first conversation on health care costs. Just Colorado Medicine for March/April 2014

last month the University of Virginia’s Miller Center released a report at the National Press Club in Washington, D.C., co-chaired by former Colorado Gov. Bill Ritter, examining how the nation’s governors and other state leaders can transform the current health care system into one that is more integrated, coordinated, patient-centered and cost effective. Other states have preceded Colorado in attempting a consensus building approach, and others will no doubt follow. Some may progress and find common approaches, some will look more like finger pointing exercises than deliberative bodies, and some may default into a zero sum report where the participants essentially fight to a draw. While regional variation in health insurance premium pricing is hardly revelatory, newly available, lay-accessible (and thus politically accessible) data and studies will energize this latent, insider debate. No doubt, when the data and trends from Colorado’s All Payer Claims Database are put under the microscope of a long-term study forum dedicated to the cost of care, the questions regarding pricing and cost/value variances will no longer be rhetorical. Some variances may be well understood and able to withstand scrutiny while others may be less defensible. Make no mistake that a long-term study forum will generate heat as well as light. In Colorado, there is a time-honored tradition of coming together under pressure when others seem to come apart, to fix problems rather than blame. Most recently, Gov. Hickenlooper convened experts and practitioners to produce a thoughtful, evidence-

based set of strategies to reduce the risk of opioid abuse. Our most recent survey of Colorado physicians reflects an understanding that the urgent mission to bend the cost curve requires a similar convening to find common purpose, one that is composed of those in the exam rooms as well as the boardrooms. The issue is complicated; there is no single variable driving costs, and there are no silver bullets or villains. n

In Colorado, there is a time-honored tradition of coming together under pressure when others seem to come apart, to fix problems rather than blame.

Join Now! Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org

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Cover Story

Taking a closer look at health care costs

Steven Brill, Journalist Kate Alfano, CMS Contributing Writer

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Colorado Medicine for March/April 2014


Cover Story Steven Brill (SB): The idea of informed choices involves two things: information and choice. It is entirely possible and should be mandatory that everyone – patients, public, policymakers – has information about what a particular health care procedure costs, who’s getting the money and even how they figured out how much it should cost. Having the information is one thing. Having the choice once you have the information is a whole other thing.

Steven Brill Editor’s note: The Colorado Medical Society is exploring the complex issue of health care costs in each issue of Colorado Medicine this year. The January/February issue featured a column by Jay Want, MD, CMO of the Center for Improving Value in Health Care. He identified three tsunamis of change that are affecting every aspect of American life, including the effort to reduce the cost of health care: debt, data and deciders. Read last issue’s cover story on www.cms.org. Health care costs: Q & A with Stephen Brill, author of “Bitter Pill: Why Medical Bills Are Killing Us” Journalist Stephen Brill’s special report in TIME magazine, “Bitter Pill: Why Medical Bills Are Killing Us,” investigated hospital billing practices and why U.S. health care spending is out of control. That March 2013 issue of TIME marked the first occurrence in the magazine’s history that the entirety of feature space was written by one contributor, and its publication sharply raised the profile of the health care cost debate. Colorado Medicine sat down for an exclusive interview with Brill after he spoke at an IMA Foundation forum that brought together business leaders, legislators and industry experts to discuss why health care costs are so high and how these costs affect our communities. Colorado Medicine (CM): In a digital age, given transparent information, is it now possible for more patients to be able to make informed choices? Colorado Medicine for March/April 2014

To take two different examples: If on the way out of here I slip and fall, the ambulance is going to take me to the nearest hospital. I’m not going to exercise any choice in what I pay or to whom I pay it. That’s a good thing; I want to get to the nearest hospital. The second example would be if I had some terrible disease like cancer and my doctor says there’s one drug that is the drug I need to put this in remission. I may have a lot of information about what the drug costs but I don’t have much choice. The kind of reform we need to aim for is first, information. Second, traditionally regulators have interceded where the market can’t work because there isn’t real choice. I think this is an argument that when you give a patent for a crucial cancer-fighting drug so no one can copy it – which is a good thing, you’re rewarding the creator of the drug – I think you should be regulating the profit that can be made from it. Otherwise you have what we have in this country, much higher costs than any other country for those types of drugs. CM: What will it take to make true price transparency a reality? SB: There already is so much regulation in the health care system and there are already two players, Medicare and Medicaid, who pay for all these services and their costs are compiled and kept. With the advantage of everyone being able to analyze and organize data so easily, having the information is increasingly less difficult. Having the information for individual patients is harder because I don’t know what deal my insurance company has

made with Hospital A versus Hospital B. I don’t know – and my insurance company probably won’t even tell me in many cases – whether I’m better off to have my wife give birth at Hospital A versus Hospital B assuming they are of the exact same quality. The insurance company may have just been out-negotiated at Hospital B and I pay for that. That’s crazy. The transparency, as any doctor in Colorado will tell you, isn’t really the chargemaster, the hospital’s list price. It should start with that but the real transparency is what the provider is actually charged in real life to people who are insured – most people and more people with the advent of the Affordable Care Act. CM: Are you familiar with Colorado’s All Payer Claims Database? How will it impact the market? SB: It’s so obvious that it’s a great tool. If I were an insurance company or hospital, I would be very uncomfortable about it. In the world of medical economics, if there’s something in the market that both hospitals and insurance companies are very uncomfortable about, it sounds like a pretty good thing. I don’t know what it’s really going to do but I’ll tell you what it should be. If I am insured by XYZ Insurance Company and I can go to any one of 10 providers for a colonoscopy, what I want to know is what the insurance company pays each of those 10 providers assuming it doesn’t pay them the same thing, which it won’t, and what my copay or coinsurance is. Second, I’d like to know if I had Insurance Company ABC instead of XYZ, how different a deal that would be. It’s one thing to focus on premiums; that’s important. Then in a world of high coinsurance and deductibles, it’s also important to focus on which insurance company has struck the best deal. If I owe 20 percent of $100 versus 15 percent of $1,000, I’m better with the 20 percent coinsurance on the $100. CM: Are the matters of excessive leverage by one player over another an issue

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Cover story (cont.) for state legislation or are they more about reform at the congressional level? SB: It’s both. If the two biggest hospitals in a community merge, what they will say in their press release is they’re doing it to create all types of synergies and cost efficiencies and it’s going to result in lower costs for everybody and this is a wonderful thing. It may result in a much higher salary for the CEO because he now gets to run something twice as big but the press release will say, “we’re doing this to save money.” Well, we don’t know that because we don’t know what they charge or what the insurance company pays them. We need to be able to say: “In 2013 you were two hospitals competing and you charged Aetna this amount and now that you’re one hospital, Aetna’s being charged 20 percent more. Can you run through how this is saving everybody money again?” Generally, in any democracy or free market, information is a pre-requisite for everything working. Once you have the information, maybe you see you need some regulation, too. CM: What might be appropriate when it comes to regulation? SB: For starters, controls on drug prices – particularly prescription medicines

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where [companies] have patents and have a near monopoly on that drug. Your doctor prescribes that drug and he may or may not have a consulting agreement with the drug company. The only thing you know is your doctor says this is the drug you must take and you or your insurance company is going to pay whatever the drug company charges. That’s one area of regulation. The other area would be the concentration of provider power so that hospitals can’t keep consolidating and buying up doctors’ practices. It sounds good because then they’re providing coordinated care and the hospitals argue that if we buy up the second hospital in town, we’ll have these economies of scale. It’s clear to me that every study on the after effects of that is that prices go up. CM: If you were speaking directly to the chairman of the health committees in the Colorado state legislature, would that be your answer about how to deal with the imbalance of power? SB: My answer would be, if you have a community where you can demonstrate that one provider has an 80 percent share of the market, then you can demonstrate that compared with Fort Collins where there are five providers who split the market, their prices are X percent higher, then you could sue to

break them up, you could get the Justice Department to sue to break them up or you could scare them into breaking up. I’m sure you’re more sensitive to this than I. The real threat is to doctors. It’s hard enough dealing with filling out forms for eight different insurance companies and Medicare but when a hospital comes to you and says, “We’ll buy your practice for X, we’ll pay you a salary that’s basically the same as what you’re taking in now but you don’t have any of this hassle anymore,” that sounds good until you read the provisions of the contract, some of which have been sent to me by doctors who are pretty angry. Down in the contract it says that if you quit, that’s fine, you just can’t practice within 300 miles of here for the next 10 years. CM: Are you troubled by the trend of hospitals buying up physician practices? SB: It troubles me but I understand it. Doctors, I assume, don’t go to medical school because they really like filling out forms and fighting with insurance companies. On the other hand, they don’t go to medical school because they really like the idea of a boss telling them, “you ordered 6 percent less of this test last month, what’s wrong with you?” I got an e-mail right after the article

Colorado Medicine for March/April 2014


Cover Story came out from a salaried doctor in one of the hospitals I had written about who copied an e-mail he got from the supervisor of his department saying “last quarter you were 4 percent down on this very expensive test” with an enclosed graph. The last sentence was “you’d better get these numbers up.” Well, what is he supposed to do? There’s always the chance that the patient didn’t need the test, right? So the choice is do you want to fill out all the paperwork or do you want some guy telling you you’re supposed to be ordering tests? Neither one is a very good place. CM: Do you anticipate that the hospitals will vigorously oppose your proposal to abolish the chargemaster and why? SB: No one defends it. What the American Hospital Association said was, “yeah, yeah, you’re right about the chargemaster but nobody pays it anyway so it doesn’t really matter. We’ve been trying to abolish it for years.” Then there’s an association of CFOs of hospitals and they attack the article saying, “anyone who has bothered to follow our work would see we’ve had committee meetings and task forces for the last 10 years about how to abolish the chargemaster.” Well, what is that about? If you want to abolish it, abolish it! Change it. You could just say, “alright, our new chargemaster is 50 percent higher or 100 percent higher than what Medicare charges.” CM: What would you transition it into? SB: Hospitals are $700 billion or $800 billion of the $2.8 trillion [in health care spending]; they’re a fairly big industry. They’re all big businesses, hundreds of millions of dollars, billions of dollars. Name another business where they actually don’t know what their costs are for providing a service. They just don’t know, [they claim], and they won’t look at Medicare for that because they refuse to acknowledge that Medicare actually is measuring their costs. So what you would transition it into is the way any enterprise is run: Here’s what our costs are, therefore, we should

Colorado Medicine for March/April 2014

target making 20 percent, 40 percent, 60 percent over our operating costs, whatever it is, and that allows us to cover overhead. That’s what we’re going to charge, that’s what we’ll explain to people and that’s the way any business is run. The only businesses that aren’t run that way are hospitals and universities. CM: What are your recommendations to address costs associated with defensive medicine? SB: The malpractice reform I’ve seen that I think makes the most sense is giving doctors and hospitals and other providers what’s called a “safe harbor.” If a doctor has followed a specific set of procedures, then the burden of proof shifts to the plaintiff’s lawyer to prove why the doctor should have made an exception in the case. If I come in and say I fell off my bicycle and hit my head and they only give me one of two tests and I leave the emergency room and die the next day, the plaintiff’s lawyers will say, “You should have given the second test to be extra sure.” If the doctor can say the standard procedure is just to give the one test, the second test is just one step too far, then the doctor would get the case dismissed. You’ve basically changed the burden of proof if the doctor is practicing according to norms set in advance. CM: In your research, was it your impression that there is an inverse power curve for the working uninsured – that they pay significantly more than their insured counterparts for equivalent services? SB: They do because they don’t have any bargaining power. If you’re insured, insurance companies try to bargain in advance for what you’re going to pay that provider, especially if the provider is in the network. That’s just the way it’s set up. I actually think the insurance companies by and large are being forced to pay too much money because the market needs regulation when it comes to a lot of hospitals that have high concentrations of bargaining pow-

er, and drug companies, device makers that have near monopolies on the products they sell. CM: At the IMA event you said that doctors and nurses are the only ones not on the “gravy train.” Could you expand on that? SB: If you look around, the irony of ironies is that the ultimate emblem of how screwed up the marketplace is is that the people actually providing the care are the ones who haven’t enjoyed the gold rush that everyone else has. If you’re really good at it, you can make more money as a sales manager selling CAT scan equipment than you can curing cancer. A lot of docs have gamed the system by having consulting contracts with device makers, giving speeches to drug companies, or buying or starting their own labs so they can send the lab test to their lab. Even then, they’re just the grunts doing the work. Name a hospital where the most highly regarded doctor in the hospital makes more money from the practice of medicine than the CEO of the hospital makes from being CEO. CM: What can CMS members do to influence the cost of care debate? SB: They can start by joining hospital boards and firing the consultants who by coincidence consult with every hospital and therefore set their peer group salaries that everybody pays for the executives of the hospital. They can drive down the profit margins by lowering prices and providing more care and more aid to the people who need it, and have a much more aggressive policy for giving out financial aid. They could get on the backs of their congressmen and ask them why they keep voting to prevent Medicare from having the ability to bargain with pharmaceutical companies and device makers and diabetes test strip makers for the price of all the stuff that Medicare buys. Those would be good starters. n

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Features

Revisiting the road map Kate Alfano, CMS contributing writer

CMS Board reviewed strategic plan in January In 2010, after broad membership input and review, the Colorado Medical Society Board of Directors adopted a longterm strategic plan designed to provide a road map for CMS. The plan set a vision for meeting the challenges facing Colorado physicians and it has guided CMS staff and the Board of Directors in program development, budgeting and defining success. In 2013, the CMS board decided to review the assumptions underpinning the current plan as well as the progress in implementing the plan, and set aside the weekend of Jan. 17-18, 2014 for a strategic plan retreat. During the retreat, attendees developed a variety of recommendations to enhance CMS’ progress in achieving our strategic goals. These recommendations spanned the areas of governance, advocacy, communications and education. The ideas formulated and vetted by breakout groups included items like expanding the delivery models for professional development, creating new membership units and restructur-

ing representation in the CMS House of Delegates and on the board, and pushing for legislation to create a bill of rights for physicians contracting out their services. The CMS executive committee has reviewed each idea and provided a recommendation to the board. These recommendations will be presented at the March 14 board meeting and further vetted. The revised strategic plan will be presented to the CMS House of Delegates at the 2014 Annual Meeting in Vail. Background materials Several documents provided to the board gave crucial framing to attendees’ work: results of an all-member survey, an environment scan, a list of major CMS accomplishments between 2011 and 2013, and the results of a board questionnaire on CMS’ internal strengths and weaknesses as well as external opportunities and threats. Analyses of the all-member survey provided comparisons to prior member surveys on key questions. It revealed a

Promoting health care decisions that are non-duplicative, evidence-based, free from harm and truly necessary

Visit www.cms.org/choosing-wisely

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decrease in the levels of concern about a number of issues over the past three to five years including the financial viability of small practices, payer issues, payment reform and access to care. Medical malpractice and health care quality and cost remain top priorities. It showed that members continue to look to CMS primarily for communications and advocacy. The survey administrator concluded that maintaining physician engagement in this time of constant change is an ongoing challenge that the next strategic plan will need to continue to strive to address. CMS commissioned the Center for Improving Value in Health Care (CIVHC) to conduct the environmental scan, which outlined the changes occurring in Colorado health care, with a particular emphasis on the impact on physician practices in terms of care and economics. CIVHC noted the following delivery system trends in their report: Integrated primary care and behavioral health can address high-cost patients with chronic conditions; hospital systems are expanding, employing more physicians; increased data availability is affecting care delivery and physician-patient interactions; health information technology is expanding but not universal; patients want full access to medical information, cost transparency and engaged doctors; and doctors are burning out from increased administrative tasks. “While the future of health care is still uncertain, there are signs that indicate Colorado Medicine for March/April 2014


Features the direction of change and the interdependence of health care delivery and payment is central to innovation,” the authors stated. “Physicians must help lead the movement toward integrated care and outcomes-driven payment. Visible leadership will be a key component to the success of this evolution of care.”

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org/join to learn more about the benefits of becoming a member

For more information and an application to join, call Tim Yanetta at 720-858-6306 or e-mail Tim_Yanetta@cms.org

The list of CMS’ major accomplishments included achievements in maintaining a stable liability climate, protecting the physician-patient relationship in the care of injured workers, educating physicians about integrated approaches to care delivery, advancing patient safety, standardizing prior authorization, and many more. Finally, the pre-questionnaire identified strengths, weaknesses, opportunities and threats. To provide focus to the many thoughts received, attendees of the planning retreat “voted” on what they felt were the top three items in each of the four categories. Examples of CMS’ identified internal strengths were: the size and diversity of our membership, a positive track record, and hardworking CMS staff. Some weaknesses were: the brewing medical “class war” between primary care and other specialties, historical silence on racial and ethnic concerns, and membership diversity challenges including the increasing number of employed physicians. Respondents identified external opportunities in the economic effects of the Affordable Care Act, the governor’s State of Health program, and the demand for innovative practice models. And they saw as threats hospitals and businesses taking the lead on “integrated” practice rather than physicians, continuing attempts to undermine the ACA, and trial lawyers’ political power and potential for success. CMS is grateful to all members who contributed to the all-member survey and to the board members for their work at the strategic plan retreat. CMS will keep members updated as the revised strategic plan develops. n

Colorado Medicine for March/April 2014

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Features

Legislative update Susan Koontz, JD, CMS General Counsel

Action picking up as General Assembly hits halfway point The 2014 Regular Session of the Colorado General Assembly has reached the halfway point, and action is picking up at the Capitol. The Colorado Medical Society is tracking more than 40 bills this session to ensure legislation benefits physicians professionally and helps improve the health and wellness of Colorado patients. With staff support, the CMS Council on Legislation (COL) reviews each bill to understand its intent, its possible outcomes and the political landscape to collectively determine how and at what level CMS should engage. Below are a handful of bills of particular interest to CMS members and supporters. Some have been drafted and introduced successfully thanks to the deep involvement of many CMS physicians and staff through task forces and stakeholder meetings convened by CMSfriendly legislators. Supported by COL HB14-1054: Restrict Minors Access Artificial Tanning Devices This bill restricts the use of artificial tanning devices for minors under the age of 18. The COL voted to support the bill. As of publication, the bill passed the House, helped by testimony from CMS Past-president Jan Kief, MD, and has been assigned to the Senate Health and Human Services Committee. HB14-1207: Household Medication Take-back Program This bill requires the executive director

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of the Department of Public Health and Environment to establish a household medication take-back program to collect and dispose of unused household medications – an important action in the effort to reduce the abuse of prescription drugs. The program allows individuals to dispose of unused medications at approved collection sites, and for carriers to transport unused medications from approved collection sites to disposal locations. The bill specifies that collection sites, carriers and disposal locations that act in good faith are not subject to liability for incidents arising from the collection, transport or disposal of medications. The COL voted to support the bill with the recommendation from the CMS Prescription Drug Abuse Committee, finding it in line with CMS policies on reducing prescription drug abuse in Colorado. HB14-1283: Modify Prescription Drug Monitoring Program This bill was introduced in the House in mid-February and assigned to the House Health, Insurance and Environment Committee. It makes the following modifications to the electronic prescription drug monitoring program (PDMP): • Allows physicians or pharmacists to delegate query tasks to registered delegates; • Provides unsolicited reports to notify prescribers and pharmacists of potential problems;

• Requires PDMP registration of physicians, but not mandatory use; • Allows use of PDMP data for public health reporting and health care coordination; and • Requires daily uploading of data from pharmacies to the PDMP system, which is an administrative change from the current two-week requirement. The COL and CMS Prescription Drug Abuse Committee also voted to support this bill. CMS physicians and staff have been an integral part of the Colorado Consortium on Prescription Drug Abuse Prevention that made the recommendations that are outlined in the bill, demonstrating the influence of CMS in the statewide effort to reduce prescription drug abuse. As of publication, the bill passed the House Health Committee with Dr. Patricia VanDevander providing expert testimony. SB14-18: Prohibit Nicotine Product Distribution to Minors and HB-1263: Tobacco Products Under 21 Under current law, it is illegal to furnish tobacco products to individuals younger than 18 years of age. This bill expands the prohibition to include all nicotine products and makes other conforming amendments concerning the liquor enforcement division's enforcement of the law. The COL supports this bill.

Colorado Medicine for March/April 2014


Features HB14-1278: Sunset Workers’ Compensation Physician Accreditation Program This bill implements the recommendations of the sunset review and report on the workers’ compensation accreditation program (WCAP) for medical professionals, administered by the Division of Workers’ Compensation in the Department of Labor and Employment by continuing the program until 2025, and allowing the division to set fees for WCAP training programs and materials administratively rather than specifying the amount of the fees in statute.

an ND to dispense, administer, order or prescribe medicines or to perform minor office procedures. And the bill increases the size of the naturopathic medicine advisory committee from nine to 11 members by adding three ANMCBcertified and state-registered NDs to the committee and eliminating one member who is a doctor of medicine or osteopathy.

The COL supports this bill.

The fight against SB14-128 and the next bill in this summary, SB14-32, are part of CMS’ continuing effort against unsafe scope of practice legislation that threatens public health and the safety of Colorado patients.

Opposed by COL HB14-1068: Mandatory Physician Reporting of Patients to the Department of Revenue with Medical Conditions That Make Driving Dangerous This bill would have required a physician to report a patient to the state for any conditions that compromise their ability to drive a vehicle – “loss, interruption or lapse of consciousness or motor function” – imposing both criminal and civil penalties for failure to report. The bill also would have removed physician immunity for reporting to the DMV thereby exposing physicians to liability by third parties.

The COL strongly opposed this bill and as a result of the advocacy of CMS and its allies, the bill was postponed indefinitely in the Senate Health Committee.

SB14-32: Naturopath Providers Treat Children Current law prohibits complementary and alternative health care practitioners and registered NDs from treating children under two years of age, and re-

quires those providers to obtain parental consent and make specified disclosures to parents before treating a child two years of age or older but less than eight years of age. The bill repeals the restrictions on the ability of alternative health care providers to treat children of any age. This bill passed out of the Senate Health and Human Services Committee in late February. The COL strongly opposes this bill. The Colorado Medical Society continually demonstrates influence at the Capitol thanks to strong lobbying efforts and through the engagement and involvement of dedicated physicians on the Council on Legislation. Active involvement in advocacy is crucial to Colorado physicians and patients, and CMS encourages anyone interested to get involved. Go to www.cms.org/advocacy for more information. n

COL opposed the bill and CMS President-elect Tamaan Osbourne-Roberts, MD, and COMPAC Chair David Ross, DO, offered strong testimony against it in February before the House Health, Insurance and Environment Committee. After a strong lobbying effort by CMS and others, the committee voted to postpone indefinitely the legislation, effectively killing the bill. SB14-128: Modify Naturopathic Doctor Act This bill allows a naturopathic doctor (ND) who does not satisfy the education and examination requirements determined last year by HB13-1111 but who holds an active certification in good standing from the American Naturopathic Medical Certification Board to obtain a state-issued ND registration. The bill also eliminates the ability of

Colorado Medicine for March/April 2014

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Colorado Medicine for March/April 2014


Features

CMS physicians lobby Capitol Hill in Washington D.C. Alfred Gilchrist, CMS Chief Executive Officer

Colorado congressional delegation supports SGR repeal, clean claims federalization Colorado Medical Society (CMS) and component society leaders attending the AMA National Advocacy Conference (NAC) in Washington, D.C., took to Capitol Hill on March 5 for meetings with the nine-member Colorado congressional delegation. Led by CMS President John L. Bender, MD, and President-elect Tamaan Osbourne-Roberts, MD, the physician delegation had an assignment to press medicine’s case on two critical “asks”: Urge co-sponsorship for H.R. 4015/S. 2000, the SGR “fix,” and designate the Colorado Clean Claims Initiative by federal Health and Human Services (HHS) as a national pilot. H.R. 4015 and S. 2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, permanently repeals the flawed Sustainable Growth Rate Medicare physician payment formula, institutes a modest update for five years and includes incentives and a pathway for physicians to develop and participate in new models of care delivery and payment. The vast majority of national and state physician organizations have publicly stated support for the bill.

road, well over a decade ago. Even so, the physicians did not fully know what to expect. The Colorado Clean Claims Initiative is an effort by the state of Colorado, strongly supported by CMS, to standardize CPT claims edits across all private payers. It is estimated that standardization of claims edits (there are millions of them) would save $80 million to $100 million a year in Colorado alone. The physician delegation was advised by CMS lobbyists that the congressional delegation would be much less familiar and most likely unaware of the Colorado Clean Claims Initiative, and that more time may be needed to level them up to an understanding of our request to federalize the project.

In the first meeting of the morning with all of the Colorado physicians looking on, Dr. Bender made the pitch for cosponsorship of H.R. 4015 to Congressman Mike Coffman (R-CO-6). Rep. Coffman replied that everything he’d heard about the bill was good and that he would be making a decision on it in the afternoon in a meeting with his staff. Next Dr. Bender teed up federalization of the Colorado Clean Claims initiative; Coffman not only stated his support for the initiative, but also offered to help draft a Colorado delegation letter to HHS. In a harbinger of meetings ahead, AMA Immediate Past President Jeremy Laza-

Colorado’s congressional delegation was already very familiar with the SGR issue. They had voted many times to stop scheduled SGR payment reductions and to provide modest fee schedule updates. CMS had been lobbying them on the SGR debacle literally since the first time Congress kicked the can down the

(from l to r) Thomas Mohr, DO, Rep. Mike Coffman (R), CMS President John L. Bender, MD, and CMS President-elect Tamaan Osbourne-Roberts, MD.

Colorado Medicine for March/April 2014

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D.C. visit (cont.) rus, MD, of Denver, asked Coffman, “Can we circle back on the SGR discussion?” Coffman literally threw up his hands and exclaimed, “Look, I don’t want you to worry about it; I’m for it. It needs to be repealed; we are going to get this done this year.” The room spontaneously erupted with thunderous applause. In the early afternoon meeting with Colorado’s two U.S. senators, Dr. Bender led with the SGR co-sponsorship. Sen. Mark Udall immediately responded, “I’m committed, what else have you got?” To the second pitch, federalization of the clean claims initiative, he told the group, “I’m for it. What will it take to move it?” Sen. Michael Bennett, who had previously voted for S. 2000 as a member of the powerful Senate Finance Committee, expressed a similar sentiment. The two senators had worked together on an administrative simplification provision of the Affordable Care Act, the precise language that would allow the HHS secretary to designate Colorado’s Clean Claims Initiative as a federal pilot. First-time NAC attendee Gerald Kirshenbaum, MD, president of the AuroraAdams Medical Society, said, “The AMA NAC was excellent – educational, entertaining and eye-opening. Of course I was aware of efforts to reverse the SGR but I learned of the in-depth approach the AMA took to encourage its repeal.”

Sen. Mark Udall, (D), and CMS President John L. Bender, MD, discuss SGR repeal. “The best part of the conference was going to the Hill,” he continued. “I have heard many times of the importance of contacting your representatives in Washington about issues of concern, but really didn't understand until yesterday of the efficacy of these efforts. During one meeting we literally accomplished bringing one gentleman from on the fence to committing to vote for the SGR repeal bill. They all really did listen.” Also during the conference, Sue Birch, BSN, RN, MBA, executive director of the Colorado Department of Health Care Policy and Financing, was awarded the AMA’s 2014 Nathan Davis Award for Outstanding Government Service. HCPF

administers Colorado Medicaid and the Child Health Plan “Plus” Program. This award is one of the most prestigious honors extended to elected officials and government employees for outstanding endeavors that advance public health. She was one of four honorees chosen from among 400 applicants nationwide. Dr. Bender nominated Birch for the award. “Sue Birch is among the country’s most accomplished leaders for implementing community-based, patient- and primary care-centered innovations that improve outcomes and reduce costs,” Dr. Bender said. “She is held in the highest regard as a trusted and skilled leader who has pulled together the fragmented and costly Medicaid program into a lean, viable, high-performing system.” Dr. Osborne-Roberts said NAC delivered multiple victories for Colorado’s doctors, from garnering support for the SGR reform bill and obtaining unanimous support for the federalization of the Colorado Clean Claims Task Force, to Birch’s recognition. “Coupled with the rousing presentations from multiple nationallyrecognized speakers, as well as the camaraderie enjoyed by all in attendance, the meeting was a through-and-through success for Colorado.”

(from l to r) Kathy Lindquist-Kleissler, Aaron Burrows, MD, Rep. Ed Perlmutter, (D), and CMS President-elect Tamaan Osbourne-Roberts, MD. 16

Dr. Enno Heucsher from Mesa County Medical Society concurred, saying, “The NAC was very productive this year and we were excited to see the Nathan Davis award go to Sue Birch.” n Colorado Medicine for March/April 2014


Colorado Medicine for March/April 2014

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Colorado Medicine for March/April 2014


Features

Health care exchange update Kate Alfano, CMS contributing writer

Payment issues may start in March Open enrollment in Connect for Health Colorado, the state’s health insurance exchange, ends on March 31. Exchange staff anticipate a surge of patients signing up for health plans before the deadline. So far, Connect for Health Colorado reports that close to 85,000 Coloradans have purchased private insurance plans and roughly 56 percent of these enrollees qualified for tax credits and financial assistance. Nearly 136,000 have qualified for Medicaid since Oct. 1. But with the newly insured comes a risk for payment issues to physician practices starting in March due to the 90-day grace period. Per federal rule, patients who receive federal subsidies to purchase exchange plans have a 90day grace period for non-payment of premiums. During the first 30 days the health insurer must pay for claims as if the patient were eligible, but in the last 60 days they can suspend claims. If the patient’s coverage is cancelled after 90 days because of non-payment of premiums, the insurer may deny all suspended claims for services furnished during the 31-90 day time period. Physician practices could therefore be in a position of providing services for up to 60 days, only to be stuck with the prospect of either having to absorb the costs as bad debt or attempting to collect arrears from patients who may not have the means to pay these bills given that they couldn’t pay for their premiums. Federal guidance states, “Issuers should notify all potentially affected providers Colorado Medicine for March/April 2014

as soon as practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.” The Colorado Association of Health Plans surveyed six of its member plans and all reported that they offer immediate eligibility verification by phone that is updated either daily or in real-time; five can immediately report by phone the patient’s effective date and whether the patient is in the grace period. Five offer verification by electronic transaction and four offer verification by secure web portal. One plan reported that it will have a field in its core system labeled “paidthrough date” that indicates the end of the month that a patient’s premium is paid through. If on the date of eligibility check that date is more than one month past, then the patient is in the threemonth grace period. That information, along with an explanation, would be provided by phone, electronic transaction or secure web portal. To help lessen the potential impact of the grace period on the viability of your practice, the American Medical Association and the Medical Group Management Association offer the following checklist for exchange implementation. 1. Double-check whether your practice’s physicians are participating with ACA exchange products. 2. Determine your practice’s ability to accept new patients.

3. Train office staff who speak with callers and patients to be able to provide resources to patients with insurance and enrollment questions. These might include the Connect for Health Colorado call center phone number and website, or personal assistance sites available through the federal exchange at www.healthcare. gov. 4. As with other insurance, check patient eligibility, coinsurance, deductibles and copays for each visit. The AMA provides a toolkit to help practices collect more at the time of service. Go to www.ama-assn.org and search “Point-of-Care Pricing Toolkit” to access this resource. 5. Be prepared to discuss out-of-pocket expenses and the cost of care with each patient. Discuss your financial policies with patients and try to collect all copayments and deductibles when the patient checks in. 6. Know the essential health benefits in your state that are in addition to the federally required benefits. The problem of cancellations due to non-payment is not new. However, it has the potential to become a bigger issue with the exchanges and federal subsidies. The Colorado Medical Society encourages members to take advantage of resources on the exchange from the AMA, MGMA and health insurers to ensure your practice is not vulnerable. n

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CMS Education Foundation Help send a student through school

About the CMS Education Foundation Founded in 1982, the Colorado Medical Society Education Foundation (CMS EF) is a nonprofit, tax-exempt charitable foundation established primarily to support educational and charitable programs in Colorado. Since 1993 the Foundation has dedicated itself almost exclusively to the funding of scholarships to incoming firstyear medical students at the University of Colorado School of Medicine. Scholarships are awarded to students who come from underserved areas, have high academic credentials, demonstrate a financial need, and anticipate practicing in a rural or underserved area.

Call 720-858-6310 for more information and to donate Colorado Medicine for March/April 2014


Features

Prescription drug abuse Kate Alfano, CMS contributing writer

CMS forms new committee to guide policy The Colorado Medical Society has convened a new committee to more closely focus on a critical issue to physicians, patients and the public in Colorado: prescription drug abuse. CMS leaders were so concerned about opioid misuse in Colorado that they created the CMS Committee on Prescription Drug Abuse for the sole purpose of addressing the matter. “Prescription drug abuse is a rapidly evolving crisis in Colorado medicine,” said committee chair John Hughes, MD. “CMS needs this committee to stay ahead of the challenges that this crisis poses.” A fact sheet on prescription drug abuse compiled by the Prescription Drug Abuse Prevention Program and released earlier this year revealed sobering statistics. • Yearly deaths in Colorado due to drug-related poisoning more than doubled from 2000 (351) to 2012 (807). Deaths involving the use of opioid analgesics more than tripled in the same time period, from 87 to 295. • More than twice as many people in Colorado died from poisoning due to opioid analgesics in 2012 (295) than from drunk-driving related fatalities (133). • Oxycodone prescriptions for Colorado residents increased 54.3 percent from the third quarter of 2007 through the third quarter of 2013.

Colorado Medicine for March/April 2014

The CMS House of Delegates approved the formation of the committee in September 2013 and the board approved the initial committee roster in January 2014. The committee will focus on three categorical areas in 2014: 1. Coordinating and working collaboratively with the Governor’s Colorado Consortium to Reduce Prescription Drug Abuse; 2. Addressing public policy issues – legislative or regulatory – that might arise that are not contemplated or are inconsistent with the CMS Platform on Prescription Drug Abuse passed by the 2013 House of Delegates; and 3. Coordinating with the appropriate state agencies and stakeholders on any changes to the Prescription Drug Monitoring Program to assure that the voice of the physician is heard and considered. The Colorado Consortium on Prescription Drug Abuse Prevention serves as the lead for the governor’s Colorado Plan to Reduce Prescription Drug Abuse. The consortium provides a cooperative, interagency-interuniversity network to enable the health care community, state agencies and others to work together to implement a strategic plan that targets six areas of the prescription drug abuse issue – the Prescription Drug Monitoring Program (PDMP), treatment, prescriber and provider education, safe disposal,

public awareness, and data/analysis. The consortium assigned a workgroup to each focus area. “I think we’re making very meaningful progress in each of our focus areas,” said Robert Valuck, PhD, RPh, director of the consortium and professor in the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. “Each work group is generating a variety of deliverables – from legislation to new permanent drop box locations, to educational programs, to public awareness/PSA campaigns – each of which is a critical element in our overall strategy to address the problem in our state.” He encourages CMS-member physicians to volunteer to serve on one of the consortium work groups to provide the physicians’ perspective. Valuck will speak about prescription drug abuse at the 2014 CMS Spring Conference in May, using a combination of stories and movie clips to raise awareness of the problem of prescription drug abuse in Colorado. He will generate discussion and sharing among physicians regarding possible ways they can promote safe use, safe storage and safe disposal of medications, and offer an overview of what is happening at the state level with the consortium, the attorney general’s substance abuse trend and response task force, and various community coalitions.

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Rx drug abuse (cont.) The CMS Prescription Drug Abuse committee held its first meeting on Tuesday, Jan. 21 to discuss legislation under consideration by the Colorado General Assembly. HB14-1283, Modify Prescription Drug Monitoring Program, was introduced in the House in mid-February by Rep. Beth McCann (D), Sen. Linda Newell (D) and Sen. John Kefalas (D), and assigned to the House Committee on Health, Insurance and Environment. HB14-1283 would permit delegated access to the PDMP, allowing a physician or pharmacist to delegate query tasks to registered delegates. It also authorizes functionality to provide unsolicited reports to notify prescribers and pharmacists of potential problems. It requires physicians to register for the PDMP – but does not mandate usage. It allows use of PDMP data for public health reporting and health care coordination. And it requires daily uploading of data from pharmacies to the PDMP system, which represents an administrative change from the current two-week requirement. Though the bill will likely have amendments as it moves through the legislative process, the committee’s

initial review showed that it is largely consistent with CMS policies on the PDMP and members unanimously voted to recommend support of the bill to the CMS Council on Legislation. Important work to upgrade the functionality of the PDMP through an upgrade to the program software will be the focus of a future story. Another bill under consideration, HB14-1207 or Household Medication Take-back Bill, would create the necessary infrastructure for a permanent take-back program. It would establish a household medication take-back program to collect and dispose of unused household medications, pending final rules from the U.S. Drug Enforcement Agency (DEA) to allow pharmacies to take back controlled substances. The committee will meet in person every other month and conduct business by e-mail between meetings. Members will continually review the CMS platform on prescription drug abuse and make recommendations to the Board of Directors when amendments to the platform are needed. They will also guide CMS’ effort to increase physician and public awareness of the problems surrounding prescription drug

abuse, and work to improve data on the issue so solutions are reflective of the need in Colorado. Members with interest in the issue can still join the CMS Prescription Drug Abuse Committee. Contact terry_ boucher@cms.org. Hughes described the desired composition of the group: “It is important that the committee have physician members with a diverse array of perspectives and backgrounds. These include primary care physicians, where there are differing perspectives from each: Emergency medicine, family medicine and occupational medicine. “Another perspective is from physicians advising medical insurance companies, the Colorado Division of Workers’ Compensation, as well as physicians advising medical malpractice carriers. Key specialists include chronic pain specialists, neurologists, toxicologists, palliative care physicians and addiction specialists. Finally, the committee should have physician educators as well as physicians in educational programs from Colorado educational institutions.” n

Educational Opportunity The Colorado Medical Society encourages all members to take advantage of education on prescription drug abuse developed by the Colorado School of Public Health. They present “The Opioid Crisis: Guidelines and Tools for Improving Chronic Pain Management,” an online, evidencebased professional development activity that examines best practices and universal precautions for treating chronic pain. An accompanying toolkit includes resources for clinicians to use to help them manage chronic pain patients including sample patient questionnaires and contracts, assessment tools, applications for calculating morphine equivalent doses, and more. Go to www.cms.org/resources/opioid-crisis-cme-andtoolkit to access the CME activity and toolkit. 22

Serving the CME needs of Colorado physicians Your bridge to quality improvement in health care

Accredited CME is education that matters to patient care. For more information contact the Colorado Medical Society CME office at 720.858.6309

Colorado Medicine for March/April 2014


Colorado Medicine for March/April 2014

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Features

Medical marijuana Kate Alfano, CMS contributing writer

Physicians and marijuana: Q & A with Larry Wolk, MD Larry Wolk, MD, is the executive director and chief medical officer of the Colorado Department of Public Health and EnvironLarry Wolk, MD ment. Previously, he served as chief executive officer of the Colorado Regional Health Information Organization (CORHIO), Colorado’s nonprofit, state-designated health information exchange. Wolk is a practicing pediatrician. He is the founder and executive director of Rocky Mountain Youth Clinics and served nearly five years as president and chief operating officer at Correctional Healthcare Companies. Wolk has served as the senior medical director for both Blue Cross/Blue Shield of Colorado and Prudential Healthcare of Colorado, and held regional and national roles as senior health care executive at CIGNA HealthCare. Colorado Medicine (CM): Can you provide background on the issue of marijuana and medical practice? Larry Wolk (LW): There are three tiers of physician involvement in marijuana: legalized marijuana, medical marijuana under the standard dose, and medical marijuana at excessive amounts. As of Jan. 1, anyone can go to a store and buy as much as one ounce for recreational use and have no more than one ounce on their person at any particular time. With that tier, physicians have a responsibility as do we as the public health department to make sure that the general public is 24

educated on the benefits and the detriments of marijuana to one’s health, with the focus on youth, pregnant women and folks for whom we know that either primary or secondary exposure to marijuana – like secondhand smoke – could be detrimental. For the second tier, the constitution says that the standard medicinal dose is two ounces or six plants, which is double the amount you’re allowed to have if you’re a non-medical or recreational user. In that regard the physician has to recommend it for the patient – they don’t prescribe it – and they have to attest to the condition for which the medical marijuana is being used. There are eight constitutionally allowed conditions: cachexia, cancer, glaucoma, HIV/AIDS, muscle spasms, seizures, severe pain and severe nausea, with 94 percent being recommended for pain. The third tier is the one I’m most concerned about. It requires a physician’s recommendation, the same as the second tier. But in the 10 years of this program it has been largely unregulated because, in my opinion, it’s a bit of the tail wagging the dog. I think the dispensaries have created products that require more than two ounces or six plants and have collaborated with physicians to justify under the term “medical necessity” recommending these rather large and excessive amounts for patients. In a state of 5.5 million, we have about 120,000 patients who are in our registry. Of those, we have about 3,000 requests a month for these increased amounts. I’ve seen recommendations as high as

99 plants or 33 ounces for things like pain, or to make a special oil, ointment or spray. There’s no science, there’s no peer-reviewed literature, there are no studies to support this excessive amount or this excessive use. You have a number of physicians in the state who are passively complicit in allowing for excessive amounts of marijuana to be recommended without any academic, scientific or medical knowledge to support that use. CM: What are you doing to address this third tier? LW: First, we’re optimistic that we’ll get spending authority from the state to release $7 million so we can have researchers study medical marijuana – both effectiveness and safety – so we can establish whether these increased doses are warranted. Second, we’re tightening up our role with regard to how we enter a patient’s plant and ounce count into the registry by almost blanketly stating that we’re not going to enter anything more than two ounces or six plants. Because even though a physician might recommend it, without an established community standard for medical necessity, I’m not going to put my name on letting a child get the equivalent of 99 plants and 33 ounces. CM: What do you see as the role of CMS? LW: I think the medical society should help aggregate the evidence-based information about marijuana. It’s easy to get drawn into the popular media when you see a child whose parents say has been miraculously cured of his seizures Colorado Medicine for March/April 2014


Features by marijuana. But the Epilepsy Foundation and the American Academy of Pediatrics have come out in support of our position, which is to say we don’t have any evidence to base any support for this and it could be toxic. Not only that, but what we do know about marijuana with or without THC is it can be addictive and it can impact the developing brain of a child or adolescent. So at least in the area related to kids, we could be creating a problem that’s as bad if not worse than the problem we’re trying to treat. I empathize with the parents and the medical community because we’re asking for medical necessity information where medical necessity information doesn’t exist yet. We’re backing folks into a corner to say they’re going to have to deal with two ounces and six plants because there’s really nothing that you can provide us to date that would meet the community standard for medical necessity.

LW: Ethically, it applies to the general practice of medicine’s community standard. There shouldn’t be anything unique about marijuana that we wouldn’t apply to any other medication, therapy or procedure. We have an obligation as physicians to educate our patients as to what’s evidence-based. On the flip side, patients have the right, independent of their physicians, to now gain access to one ounce of marijuana as long as they’re over 21, and physicians have the right, per the constitution, to recommend medical marijuana at the constitutionally dictated dose of two ounces if the patient suffers from any one of those eight conditions. All I’m asking is that we apply that same standard to medical marijuana, not any different or stricter standard.

Legally, medical marijuana is an affirmative defense, meaning that you have to prove that you have an excess number of plants or ounces because of a medical condition. If you have the standard amount, the physician’s recommendation and a registry card, then you’re okay. But if you have the card and the physician’s recommendation and an excessive amount when the registry says you are only allowed the standard amount, there would likely be legal implications for both the physician and the patient if they can’t demonstrate medical necessity for the increased or excessive amounts. Physicians recommending medical marijuana should consider these things when making dosage recommendations that exceed two ounces or six plants. n

CM: What message do you have for physicians? LW: This is a bit of a warning. I am now charged with the health and safety of the population. For those physicians who are recommending excessive amounts for a large number of patients, especially in association with single dispensaries and outside of their trained field of expertise, I’m referring those physicians for investigation by the board of medical examiners because there’s a possibility that they’re not practicing within the community standard that applies to the general practice of medicine. The majority of the recommendations for excessive amounts are coming from only a handful of physicians. For example, in the month of October 2013 we had almost 3,000 applications with recommendations for increased or excessive amounts. Of those 3,000, about 80 physicians made those recommendations. Of the 80 physicians, 10 of the physicians accounted for 2,000 of the 3,000 recommendations. And of those, two physicians accounted for 1,000 of those recommendations. CM: Is this a legal or ethical issue? Colorado Medicine for March/April 2014

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Features

Physician contracts with hospitals Kevin P. Perez, JD, Kennedy Childs, P.C.

Be aware or beware Beginning in July 1995, Colorado law allowed hospitals to directly employ physicians. Since that date, the law has been amended to allow hospices, community mental health centers, long-term care facilities, PACE organizations, school-based health centers and other health care centers to do the same. While these changes in the law have resulted in a limited repeal of the long-standing prohibition of the corporate practice of medicine, the Colorado legislature has made it clear that no corporate employer can exert control over a physician’s independent medical judgment so as to compromise the quality of patient care. Indeed, the legislature admonished corporate-employed physicians to be wary of external pressures that could erode their ethical practice of medicine, and to be vigilant to ensure that patient welfare takes priority over the physician’s–or his or her employer’s–financial interests. Aside from taking pains to keep one’s medical judg-

ment separate from any corporate pressure, any physician who is considering becoming employed by a health care facility needs to be cognizant of how his or her contract, employee handbooks, medical staff bylaws and the like will ultimately shape and impact his or her practice, as all these documents must be read and taken together. The number one issue for a physician who is, or is thinking of becoming, employed by a health care facility is to fully understand the rights and obligations set forth in the employment contract. The term that gets the most attention early on – physician compensation – is obviously very important, and the way in which pay and bonuses are calculated needs to be both clearly spelled out and fair to both parties. Given the legislature’s admonishment, employed physicians need to be especially wary of compensation programs that would reward over- or under-treatment, as such

Have an idea you want to share? Do you like something CMS is doing? Are we heading on the right or wrong track with our strategic plan?

E-mail: Letters to the editor dean_holzkamp@cms.org

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provisions could create conflicts of interest. To that end, it may be in a physician’s best interests to at least attempt to negotiate a substantial, guaranteed base salary so that performance bonuses are not so significant. Aside from compensation, physicians need to understand what they can and cannot do while they are employed by the facility. Physicians should determine the rules for sharing call; how call income and income from other sources will be treated in the compensation formula; their work/office hours; whether office space, staffing, equipment and access to facilities is adequate for their specialty; how supervision of non-physician staff will take place; what performance evaluations will take place; and what say they have as to the facility’s future decisions to hire physicians in their same specialty (which may negatively affect compensation, reduce referrals, and compete for available facilities and staff). Additionally, physicians should be aware of what the facility provides in terms of available time off, expense reimbursements, insurance programs and any other benefits. Lastly, physicians need to ensure that their referral decisions are not impacted or restricted by contractual requirements, and that they are free to refer patients in a manner that puts patient welfare first. Looking down the road, it is important that physicians fully understand how they and their employer can end the employment relationship, what dispute resolution mechanisms are in place, and what rights and obligations survive the employment contract. Physicians should Colorado Medicine for March/April 2014


Features be aware that in many contracts their rights and obligations often turn on whether the employment relationship was severed for cause or for convenience. Perhaps the biggest post-termination obligation for a physician relates to what are generally called non-compete clauses. Though these clauses legally cannot forbid a physician from practicing medicine in competition with his or her former employer, the law allows health care facilities to essentially charge a fee (liquidated damages) to former employees who practice medicine within a certain geographic area, during some set period of time. The legally permissible geographic and temporal scope of physician non-compete clauses varies depending on the circumstances, as does the liquidated damages amount, and these clauses are often subject to negotiation prior to the physician entering into the contract. Regardless of what was decided when they were hired, physicians can challenge onerous noncompete provisions after they are terminated. However, the cost of addressing an onerous provision at the end of the relationship is typically much greater than the cost of negotiating reasonable terms prior to hire (when the physician ostensibly has greater leverage). There are many more issues to be aware of when a physician enters into, or is even considering entering into, an employment relationship with a corporate health care facility. Because of this, and as a membership benefit, CMS members have access to a contracting handbook and checklist at tinyurl.com/employedphysicians to allow them to better evaluate the terms of their current or proposed employment contracts. These resources will help familiarize member physicians with key provisions of typical employment contracts to allow them to engage in informed discussions. For those who wish to move beyond self-help, CMS has negotiated for discounted and flat fee contract review/ negotiation services from Kevin Perez at Kennedy Childs, P.C. Go to tinyurl. com/employed-physicians for more information. n

Colorado Medicine for March/April 2014

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Inside CMS

Dimensions of wellness survey Kate Alfano, CMS contributing writer

Poll results to shape development of wellness toolkit In January 288 CMS members completed a survey focused on physician wellness across eight dimensions: emotional, environmental, financial, intellectual, occupational, physical, social and spiritual. A collaboration between the Colorado Medical Society and the University of Colorado’s Behavioral Health and Wellness Program (BHWP), the survey gathered information about CMS members’ perceptions of wellness. The University's Behavioral Health and Wellness Program will use the survey data to help shape the development of a physician wellness toolkit to be published later this year.

Survey participants were asked to rate their level of wellness on a scale of 1 (worst) to 10 (best). More than 66 percent of physicians surveyed rated their environmental, intellectual and spiritual wellness as “high,” with an average rating ranging from 7.9 (intellectual and spiritual) to 8.1 (environmental). In fact, more than half of all participants rate their wellness as “high” in all dimensions. Less than 10 percent of survey participants rate their current wellness as “low” in seven of the eight dimensions of wellness. However, occupational wellness is rated as “low” by more than one in every 10 participants. Less than half of partici-

pants rated their occupational wellness as either “moderate” (38 percent) or “low” (11 percent). This demonstrates that CMS and BWHP must focus upcoming wellness activities on increasing occupational wellness as well as sustaining wellness across all of the other dimensions. We encourage physicians to provide feedback on the CMS physician wellness initiative. Tools and articles are posted monthly on CMS.org. Go to www.cms. org/resources/category/physician-wellness to view these resources and submit comments. Members’ contributions support the goal of increasing overall physician wellness. n

Wellness Survey Results Percentages

Emotional Environmental Financial Intellectual Occupational Physical Social Spiritual

Low (1-3)

5%

3%

7%

3%

11%

6%

7%

3%

Moderate (4-7)

35%

24%

30%

29%

38%

37%

42%

27%

High (8-10)

59%

73%

64%

68%

50%

57%

52%

70%

# of Respondents Emotional Environmental

Financial Intellectual Occupational Physical Social Spiritual

Low (1-3)

15

8

19

8

33

18

21

9

Moderate (4-7)

102

69

86

84

110

107

118

78

High (8-10)

7.36

8.09

7.64

7.89

6.88

7.44

7.15

7.91

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Colorado Medicine for March/April 2014


Inside CMS

Wellness Survey Results Spiritual

3%

Social

Emotional

38%

11%

57%

50% High 68%

29%

3%

Financial

52%

37%

6%

Occupational

Environmental

41%

7%

Physical

Intellectual

70%

27%

73%

24%

3% 5%

Low

64%

30%

7%

Moderate

35%

59%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80%

Colorado Medicine for March/April 2014

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Gold Level Sponsors

Register now for 2014 CMS Spring Conference May 16 through May 18, 2014 Sonnenalp Resort, Vail

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BIOSPACE Colorado Drug Card COPIC Financial Services Wells Fargo IPC/Senior Care of Colorado Intel Health Solutions, LLC University of Denver Colorado Medicine for March/April 2014


Inside CMS

Spring Conference preview Tamaan Osbourne-Roberts, MD

Registration open for May 16-18 Spring Conference As president-elect of the Colorado Medical Society, it is my pleasure to announce the 2014 CMS Spring Conference, to be held May 16-18 at the Sonnenalp Resort in Vail. The theme this year, “Narrative as Persuasion: The Proven Effectiveness of Storytelling,” has invited some exciting changes to our programming from years past. Our faculty – top state and national experts – will address attendees on critical issues facing medicine in Colorado. • COPIC board member Gerald Zarlengo, MD, will address liability and patient safety. • Jay Crosson, MD, the American Medical Association’s Group Vice President for Physician Satisfaction: Care Delivery and Payment, will address physician satisfaction and practice sustainability framed

around the groundbreaking RAND Corporation study on the subject. • Robert J. Valuck, PhD, president of the Colorado Prescription Drug Abuse Task Force and coordinating center director of the Colorado Consortium for Prescription Drug Abuse Prevention, will update attendees on the effort to reduce prescription drug abuse in our state. • Michele Lueck, president and CEO of the Colorado Health Institute, will address access to health care framed around the most comprehensive study of access to care in the history of Colorado. New this year, participants will also learn how to apply tangible storytelling skills and acumen delivered by Aaron Templer, a professional communications consultant, in order to more effectively express medicine’s message on these and other issues.

We’ve also built in some extra social time this year starting Friday night, to celebrate our profession together, and perhaps share a few stories with one another. Registration is free for CMS member physicians and component society staff. Non-CMS member physicians and guests can register for a fee of $125 to cover events and meals. The hotel group rate of $155 per night for a junior suite is available until April 4, 2014. Reservations received after this date will be accepted on a space-available basis. Reserve a room through the Spring Conference registration form by contacting the hotel at (800) 654-8312 or online at www.sonnenalp.com. Go to www.cms.org for more information and to register. I hope you’ll consider attending to learn, network and be inspired. n

Join Now!

Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org Colorado Medicine for March/April 2014

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Inside CMS

2013 CMS Spring Conference Agenda May 16-18, 2014: The Sonnenalp, Vail CO

Narrative as Persuasion: The Proven Effectiveness of Storytelling May 16, 2014: Friday 6:00 – 8:00 p.m.

Social hour in the Kings Club with appetizers, live music, cocktails and dessert

May 17, 2014: Saturday 7:00 - 8:00 a.m.

Breakfast

8:00 - 9:00 a.m.

Paradise Lost, Paradise Regained - Trials and Redemption in the Life of a Doctor

Tamaan Osbourne-Roberts, MD, CMS President Elect

Stories are the natural province of physicians, but for many of us, telling our own stories remains an "undiscovered country." In this session, the CMS President-elect will take participants on a journey through his life as a doctor, emphasizing the challenges and successes he has faced in his work as a healer, and in his own journey towards health and wellness. By utilizing evidence-based narrative techniques, he will demonstrate the importance of storytelling practices to individual physicians, to the medical profession as a whole, and to the patients and communities that physicians serve.

9:00 - 9:50 a.m.

Leading With Stories - Why stories persuade us more than just facts and how leaders use them Aaron Templar

When researchers put story-watchers in a FMRI machine to see how their brains reacted, one observer said it’s as if “the brain doesn’t look like a spectator, it looks more like a participant in the action.” Stories move us. As Brené Brown, Ph.D., research professor at the University of Houston puts it, “stories are data with a soul.” They’re like an ionic attraction between our rational and emotional selves that create deeper meaning in the information we process. Telling stories is a learnable craft. During this session, you’ll learn some basics for building and crafting a story.

9:50 - 10:10 a.m.

Break

10:10 - 11:10 a.m.

“Mutiny on the Bounty?” Why many physicians are unhappy with medical practice and what can be done about it.

Jay Crosson, Group Vice-President, AMA

11:15 a.m. - 12:15 p.m. Beware the Rabbit Hole: What’s Really Going to Impact Your Practice Michele Lueck, President/CEO Colorado Health Institute

1. 2. 3. 4. 5.

What Is Affordable - Really? Do We Have Enough Providers? Health Reform And The Most Vulnerable: What Will Happen to The Uninsured, the Health Care Safety Net and Our Emergency Departments? Integration and You: What Will it Mean for Your Practice? The Empowered Consumer: Are You Ready?

Participants will leave with a fuller understanding of the context of transformation and change here in Colorado and the pressures that practices will encounter in the coming post ACA years.

12:30 p.m. 32

Afternoon break or communications consults for inspired participants. Colorado Medicine for March/April 2014


Inside CMS

Spring Conference Agenda (continued) Saturday Evening: Dessert Reception and Fireside Chat 7:00 - 9:00 p.m.

Leadership You – Spring Conference Faculty Panel How the basic practices of effective leadership empower us all to make change

Leadership starts with a sense of empowerment. Despite physicians holding implicit positions and voices of authority in our society, it’s easy to feel helpless against the forces that defend the status quo. Physicians of all stripes must accept responsibility to create the conditions that enable others to achieve a shared purpose in the face of adversity. Join us for this year’s Fireside Chat where our Spring Conference faculty – leaders in their various domains and communities – and Dr. Kathy Kennedy, Director of the Regional Institute for Health and Environmental Leadership – will discuss how leadership transcends formal positions of authority and power, and how you can join the cadre of able and willing physicians to step up as champions in improving the delivery of cost-effective, quality and safe care.

May 18, 2014: Sunday 7:00 - 8:00 a.m.

Breakfast

8:00 - 8:10 a.m.

Welcome back – Tamaan Osbourne-Roberts, MD, CMS President Elect

8:15 - 9:25 a.m.

And the Oscar for Best Actor goes to…Hydrocodone? Prescription Drug Abuse in Modern American Film: Lessons for Treatment, Prevention and Public Health

Robert Valuck, PhD., R.Ph

9:30 - 10:30 a.m.

COPIC programming - Gerald Zarlengo, MD

10:30 - 1 0:45 a.m.

Break

10:45 a.m. - Noon

Storytelling Practice Field

Death rates from drug overdose have quadrupled over the past two decades and have become the leading cause of injury death in both the U.S. and Colorado. Misuse and abuse of prescription opioids have been the primary contributor to these overdoses. Using examples from three modern American films (Valley of the Dolls, Drugstore Cowboy, and Trainspotting), Dr. Valuck will explore the epidemiology, etiology and impact of prescription drug abuse, the “tandem epidemic” of heroin abuse, and statewide initiatives underway in Colorado to address this important public health problem.

Aaron Templar

Brave souls from your cohort tell their stories. Armed with new data from the Spring Conference faculty and a sense of responsibility to lead change in our community, volunteers will put their new storytelling skills to the test in front of you, their

Continuing Medical Education and COPIC ERS points will be awarded Colorado Medical Society will post on its website at www.cms.org and notify subscribers via its electronic newsletter ASAP the number of CME credits and COPIC ERS points that will be available to earn as soon as they have been determined.

Register for the conference today at www.cms.org

Colorado Medicine for March/April 2014

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Inside CMS

ICD-10 update Marilyn Rissmiller, Senior Director, Health Care Financing

Getting involved in your transition The Colorado ICD-10 Training Coalition held its first webinar of 2014 on Feb. 18 with record-breaking registrations, demonstrating the great interest practice managers, staff and the medical community have in this month’s subject: How to get a practice’s physicians engaged in the transition to ICD-10. Getting physicians engaged in ICD-10 is one of the biggest concerns that has been raised by practice administrators. While the coalition recognizes that physicians have many other demands on their time – over and above caring for their patients – that make it difficult to focus on ICD-10 coding, physicians must start learning now to avoid a 100 percent pay cut by the transition deadline, Oct. 1, 2014. The webinar featured two practicing physicians from different practice settings and with different resources to gain a better understanding of the physician’s perspective on the ICD-10 transition. Chet Cedars, MD, is a family physician with Lone Tree Family Practice. He has been in practice in Denver for more than 40 years and currently splits his time between part-time practice and serving as the practice administrator. His practice partner practices full time and they employ five midlevel providers. John James, MD, is an allergist with Colorado Allergy and Asthma Centers. With locations throughout the Denver metro area, plus Castle Rock, Broomfield, Fort Collins and Greeley, the single-specialty group has 12 physicians and 10 midlevel providers. 34

Here are their top five takeaways for physicians. 1. Start learning about ICD-10 now. There are many resources available. Spread out the transition and the training over the next few months. “If providers understand what the additional code specificity is, what’s going to be available, and to look for those areas when they document the diagnosis, that will help,” Cedars said. “If you don’t know what’s there and you wait until Sept. 29, you’re going to be hurting.” 2. It’s not necessary for doctors to know all of the codes (or any code really); the doctor needs to know what documentation elements are required. Cedars’ electronic medical records vendor has loaded many of the ICD10 codes onto its system, which allows the practice to begin collecting diagnoses with more specificity. The vendor will update the full system in March. Cedars said physicians can use medical assistants or nurses to document some of the codes in the chart so they have a head start. The staff can also look for those codes for the physician and he can approve or change it. As far as documentation training, Cedars said it’s still an onthe-go project. “I let the employees know how they will start documenting things like we haven’t in the past but we haven’t had any formal training at this point.” 3. Focus on the diagnoses that are critical to your own specialty/practice. This will save time and (likely) frus-

tration. James’ practice focused on the top 50 codes in allergy and immunology. “We started to learn how to use the code set book and plan how we’re going to crosswalk from ICD-9 to ICD-10. We have a lot of education for our providers.” 4. Documentation is critical and only the practitioner can provide that. The coders can’t tell the physicians how to diagnose but they can give the physicians the tools they need for common diagnoses. This tells the physician what to document in their records so staff can pick the right ICD-10 diagnosis code. The concern is if the physician does not document what is needed, the coder can’t pick the right code, and if the coder can’t pick the code, the practice can’t submit a claim. Preparation is key and staff must have open communication with physicians before the ICD-10 transition. Cedars recommended that practice staff provide a printout to show physicians the difference in the codes and the difference in the specificities of the codes to give them an idea of what it’s about. 5. Don’t wait until Oct. 1, 2014 to improve your documentation; begin now to incorporate the new elements. “Looking at the new ICD-10CM code set, I realize I have a lot to learn,” James said. “I could see someone looking for the first time feeling extremely overwhelmed. We have regular documentation sessions with our consultant and we get graded on our coding. It’s not always pretty but it helps us improve.” James’ practice Colorado Medicine for March/April 2014


Inside CMS is learning ICD-10 now and will code in both code sets in September. This allows them to check back with the coding office and ensure the coders are receiving everything they need. What makes these two practices more prepared than most is that the physicians are involved. Cedars leads the way in his practice as the administrator. James’ practice has a committee of individuals that includes their chief operating officer, the director of clinical operations, the clinic manager and three physicians. Physicians must be aware of what’s happening around the state and nationally instead of burying our heads in the sand, James said. He encouraged the webinar participants to engage physicians in the process: Find common ground and approach the transition as a team. “It’s important to have an approach, take a little bit at a time and ramp it up,” James said. “We’d better get ready.” n

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Colorado Medicine for March/April 2014

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Inside CMS

Clean Claims Task Force Marilyn Rissmiller, Senior Director, Health Care Financing

Progress toward a uniform set of claim edits The Clean Claims Task Force – a group of 28 experts including national representatives from many health plans, software vendors and providers – is approximately 38 months into a fully transparent four-year project to develop a uniform set of claim edits that will be adopted by all payers having contracts with providers in Colorado. A uniform set of medical claim edits and payment rules are conservatively estimated to save approximately $80 million to $100 million per year just in

Colorado, and continues to garner interest from other states. Throughout the process the task force has solicited input from stakeholders and the public: During 2013 four separate bundles of logic rules dealing with different edit and payment rule categories were submitted for public review. Each review period required the rules to be posted for downloading from the task force website; a period for the public to consider the new rules; a period for public input; a period for the task force to

revisit and revise the rules as necessary; and the posting of formal statements addressing each request for change and what was done about it. The task force works by consensus, requiring members to achieve a substantive unanimity around any changes made before such adjustments were posted. Concurrent with the development of rule logic for the adoption of edits and payment rules, the task force has developed a set of investigative query categories for each rule to allow for adequate vetting of the edit and payment rule library being brought forth. During 2014 the task force will import a universe of existing edits and payment rules from the industry into a database and analyze them for compliance with the uniform rules for acceptance developed. This is an exhaustive and rigorous process but must be conducted for the Colorado uniform and transparently developed edit and payment rule set to have credibility with all those who use it. To achieve a downloadable library of uniformly agreed upon and transparently adopted claim edits and payment rules, the task force must enlist the help of a data analytics firm that can facilitate the necessary software and user interface to allow for query work. An exhaustive request-for-proposal (RFP) process for a data analytics vendor was conducted in late 2013 and the contract was awarded to Bishop Enterprises of Wilmington, Del. In early 2014 the task force resolved to add a step in the process as the group

36

Colorado Medicine for March/April 2014


Inside CMS prepares for the final release of a starting set of uniform edits and payment rules at the end of this year. The public review of rules was so productive that members now believe it is essential to have a public review of the complete edit and payment rule library. The group has set 2015 as the target period during which to conduct a final and full review by the public of the finished (draft) product. Legislation is currently being drafted in Colorado for this purpose.

Promoting health care decisions that are non-duplicative, evidence-based, free from harm and truly necessary

Visit www.cms.org/choosing-wisely

Reducing administrative burdens in the health care system and eliminating barriers to quality care is a high priority of the Colorado Medical Society. Additionally, administrative simplification is gaining traction at the federal level. Although the initial development of a uniform and transparent set of claim edits and payment rules has been a Colorado-based initiative, the task force has believed that its long-term sustainability would be enhanced by acceptance at the national level. With Colorado physicians receiving early indications of support from their trip to Washington, D.C. in early March for the National Advocacy Conference, the task force is optimistic the Colorado congressional delegation will help to garner interest from the Centers for Medicare and Medicaid Services in a national clean claims initiative. There is a section in the Affordable Care Act that focuses on administrative simplification initiatives and one of those requires the Secretary of Health and Human Services to seek input into the feasibility of making the development of claim edits more transparent. The Colorado task force has shown that it is feasible and actually has a “product� that could be adopted as the national model. Colorado Medical Society continues to support the work of the task force members and applauds their efforts as they near completion. n

Colorado Medicine for March/April 2014

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Inside CMS

Ted J. Clarke, MD Chairman & CEO COPIC Insurance Company

The importance of listening to our insureds In my role, I hear a lot of opinions about what COPIC should (and shouldn’t) be doing. There are thoughts that arise during internal meetings, points made by partner organizations, and suggestions from medical colleagues. While these different perspectives provide great insight, they also need to be considered alongside the most important information we receive – feedback from our insureds. In any business, listening to your customers is key to success. For COPIC, commitment to this principle exists in how we encourage open communication with every physician, medical professional, and health care facility we work with. Their thoughts and ideas are invaluable, and what they see, hear and feel is essential in guiding our decisions and the ways we support improved medicine. Over the years, we have established several touch points – from electronic surveys to personal interactions – to gather meaningful feedback from our insureds. The following quotes are examples of what they have told us. “Relationships are important to us as a practice. Price only is not the deciding factor – but it is important.” All aspects of health care are focusing on how to balance cost with value. At COPIC, we are consistently looking at ways to maintain stable, reasonable premiums and deliver services that meet the needs of insureds. We don’t look at medical liability insurance as a necessary commodity, but instead, view it as a partnership that offers necessary support. Medical professionals are facing substantial challenges, and COPIC strives to be a source for trusted guidance and expert knowledge. Our goal is to help insureds prevent adverse outcomes and improve patient safety. However, there are situations when a claim or lawsuit occurs despite best efforts. When medicine meets the standard of care, we want our insureds to have confidence in our ability to defend them. The following quote is from an insured physician who faced a claim: “Excellent use of experts to thoroughly review records to fully understand the medical issues of the case…I am very pleased with the thoroughness, intellect, and professionalism of [my attorney] and his office staff. They supported me through every step of this stressful process and fortunately we had a good outcome.” Another important part of seeking feedback is to better 38

understand what resources are important to our insureds, as shown in these comments: “We use [COPIC] all the time for making decisions about credentialing, physician problems, what is a reasonable procedure at my surgery center...” “I appreciate the risk management programs, the newsletter, and the active involvement taken with claims/ issues that arise. I view COPIC as an ally…truly supportive and involved.” “Used to validate and modify policies and procedures regarding risk management, infection control, time-outs…” These statements represent how COPIC is viewed differently by those we work with, and this feedback helps us develop programs and resources that directly address the needs and concerns mentioned. And by sharing these comments with others, there is expanded awareness on how COPIC supports medical professionals and health care systems, and what resources are available through us. “I would like to be able to earn more COPIC points online.” A simple statement, and one that provides a good example on how we take action on what insureds say. In this case, we received several similar comments about the need for “flexible” options with our education activities. We responded by expanding the offering of online courses available through our website to include interactive case studies, videos of popular in-person seminars, and other topics at the forefront of medical liability issues. Here are some comments we received from physicians who recently completed one of our online courses: “This course is the first I've done online. I was pleasantly surprised at the quality and ease.” “This interactive ‘real situation’ is a great way to learn, and makes CME valuable and interesting. I hope you create more of them!” Staying connected to our insureds is a core value that we will continue to embrace. Their feedback is instrumental to the continuous improvement that makes us better and leads to better medicine for everyone involved. n

Colorado Medicine for March/April 2014


Inside CMS

Ambassador

P R O G R A M COLORADO

One-of-a-kind program offers chance to understand “AMA equation” The Colorado Medical Society (CMS) has teamed up with the American Medical Association (AMA) for a new program that brings a CMS leader to physician group meetings around the state: the AMA Ambassador Program. Through this program, only being offered in Colorado, a member of the Colorado delegation to the AMA will present a brief presentation on the national association’s strategic focus areas, major advocacy and program initiatives, and our successful collaborations.

patients, and sometimes doing the best means working with others – others who may have different skill sets and resources. It’s not much different in organized medicine: The AMA is a crucial partner to CMS and our aim is to increase awareness of the work that they do. The presentation, “Colorado Medical Society and AMA: Shaping a Better Future for Patients, Medical Students and Physicians,” demonstrates how the two organizations work together to promote the art and science of medicine and improve public health. Physicians in attendance at your meeting will gain a better understanding of the “AMA

equation” – the different components of the organization that provide superior representation for physicians, such as governance, advocacy, research and education, and practice tools. Act quickly; this program will only be offered for a short time and spots are limited. To invite an ambassador to your meeting, contact Dianna Mellott-Yost at dianna_mellott-yost@cms.org or 720858-6321. We look forward to speaking to your members about how the AMA is working with CMS to address issues affecting physicians in our state and the ways they are working to help physicians nationally. n

Ambassador

Physicians know that the best patient care usually comes as the result of teamwork. We all want to do our best for our

P R O G R A M COLORADO

Colorado Medicine for March/April 2014

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Departments

medical news Colorado Permanente Medical Group achieves highest accreditation for continuing education of physicians The Colorado Medical Society Committee on Professional Education and Accreditation has awarded the highest accreditation level to a Colorado provider of continuing medical education, Colorado Permanente Medical Group. Colorado Permanente Medical Group provides care exclusively for more than 545,000 Kaiser Permanente Colorado members. CPMG is the state’s largest medical group practice within a health care organization; almost 1,000 physicians representing all medical specialties and major sub-specialties provide care for Kaiser Permanente members. This honor, “Accreditation with Commendation,” is awarded to CME institutions that adhere to all 22 CME criteria of the Accreditation Council for Continuing Medical Education, or ACCME, the main accreditation body for CME. Colorado Medical Society is

recognized by the ACCME to accredit CME providers in Colorado and the surrounding region. The first 15 criteria fall into three essential areas: purpose and mission, education and planning, and evaluation and improvement. To receive commendation, organizations must also demonstrate that they use CME as a tool to improve quality performance and health outcomes, and that they collaborate with internal or external stakeholders to further improve quality. With

Whether you’re looking for new opportunities or selling your product or service, CMS’ classified ad section is the place to be seen. To place your ad call (720) 858-6310

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CMS has awarded commendation to 25 percent of its CME providers. A survey of other state medical societies shows that an average of 17 percent of state CME providers have received this award and approximately 40 percent of national CME providers accredited directly by the ACCME have been awarded commendation. n

Nominate a colleague for “Physician Heroes” Physicians have been trained to be other-directed – patients always come first – which means that they frequently make their own health a low priority. Add demanding schedules, increasing administrative burden and endless technology requirements, and it’s no surprise that 30 to 40 percent of physicians experience burnout. We at the Colorado Medical Society are interested in changing this, to help physicians be healthy and enjoy long careers in medicine. One of the ways we hope to decrease burnout is with a new series in Colorado Medicine, “Physician Heroes.”

LOOKING?

commendation, these organizations will receive a six-year term of accreditation compared to the standard four-year term.

Through physician heroes, CMS will profile as many different members as we can who have gone above and beyond in the profession to help their colleagues or community. We hope physicians will be able to reflect on the meaningful difference these heroes are making in the lives of their patients and communities, see their own values reflected in these stories and be reminded of the joy of medicine that led them to join the profession.

The first hero was Frank Dumont, MD, an internal medicine physician in Estes Park who coordinated the medical response to the September floods. “I got to witness this wonderful sense of medical community where people came together and made things happen that we never thought we would have to do. ... To watch that happen with everybody so focused is one of the highlights of my career.” We have intentionally kept the definition of “hero” broad. It could mean someone who has served in the military, figured out a tricky diagnosis, volunteered with a community health program, served rural or underserved patients, traveled many miles to treat a patient or comforted someone struggling – anything that inspires others. We need your help to identify these extraordinary physicians. Please consider nominating a physician for this series by contacting Dean Holzkamp at dean_ holzkamp@cms.org or (303) 748-6113. n

Colorado Medicine for March/April 2014


Departments

medical news Sue Birch named recipient of prestigious Nathan Davis Award for Outstanding Government Service Colorado’s Sue Birch, BSN, MBA, has been named a 2014 recipient of the American Medical Association’s Nathan Davis Award for Outstanding Government Service. The Colorado Medical Society nominated her for the award. Birch is the executive director of the Colorado Department of Health Care Policy and Financing, which oversees the state Medicaid and CHP+ programs. The awards are recognized nationally as one of the most prestigious honors extended to elected officials and government employees for outstanding endeavors that advance public health. “We consider her among the country’s most accomplished leaders in the kinds of community-based, patient and primary-care-centered innovations that improve outcomes and reduce costs,” CMS wrote in the nomination letter.

“She is held in the highest regard as a trusted and skilled leader who has pulled together the fragmented and dysfunctional Medicaid program into a viable, highper forming system that Nathan Davis Award-winner Sue Birch celebrates with CMS President is at its John L. Bender, MD and President-elect Tamaan Osbourne-Roberts, MD. epicenter and career government service, demonhomegrown and locally coordinated.” strates outstanding leadership, demonRecipients of the award must demon- strates high personal integrity, has prostrate one or more of the following ac- moted the art and science of medicine tions or qualities: has greatly contribut- in or through government service, and/ ed to the public health through elected or has developed a special project that contributed to the public health of a given community or special population.

Register for the Western Health Care Leadership Academy April 11-13, 2014 in San Diego The Colorado Medical Society is collaborating with the California Medical Association, the Medical Group Management Association and the CMA Foundation to bring you the 2014 Western Health Care Leadership Academy. The conference will be held at the San Diego Convention Center April 11-13, 2014, and features a keynote address by former Secretary of State Hillary Rodham Clinton. This conference is especially relevant to physicians and nurses in all practice settings, medical practice managers and administrators, and medical students Colorado Medicine for March/April 2014

and residents. Attend to prepare for changes affecting your practice, your profession and your economic future; learn techniques to minimize financial risks and boost the bottom line; acquire skills needed to excel as a medical practice or medical staff leader; and network with your colleagues. CMS members can receive $795 “physician member” rates for the conference. Discounts are available for multiple registrations. Help represent Colorado. For more information and to register, go to www.westernleadershipacademy.com. n

Birch was presented with the award on March 5 during a ceremony in Washington, D.C. as part of the AMA’s National Advocacy Conference. n

DONATE SUPPLIES OR EQUIPMENT Project C.U.R.E. collects donated medical equipment and supplies and organizes them for delivery to people in need in developing countries. Volunteers needed locally to sort medical supplies and internationally to participate in C.U.R.E. Clinics. For more information, visit http://www.projectcureorg, call 303-792-0729, fax 303-792-0744, or e-mail projectcureinfo@projectcure.org.

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Departments

medical news Action alert: physician involvement needed to advance SGR repeal Congress has made great progress by working across party lines and across House and Senate chambers to produce a joint policy framework that repeals Medicare’s sustainable growth rate formula, but the deal is far from done. Congress must either pass this bill or another short-term fix to avert a 24.1 percent cut that will go into effect on March 31. The American Medical Association has praised the “SGR Repeal and Medicare Provider Payment Modernization Act of 2014” (HR 4015/S 2000), introduced by Rep. Michael Burgess, MD (R-Texas), for addressing the policy provisions related to eliminating the SGR. However, the bill does not include financial offsets or extender policies, which represent large hurdles to passage.

The AMA outlines some of the main provisions of HR 4015/S 2000: • The SGR would be repealed immediately. • Positive annual payment updates of 0.5 percent would be provided for five years. • The value-based payment program would be replaced with a similar Merit-Based Incentive Payment System or MIPS, which includes prospectively-set performance thresholds and offers flexibility in the imposition of performance requirements that are inappropriate for some specialties. • The effective date of the MIPS program would be one year later than the original VBP proposal, and will start in 2018. • The MIPS funding pool would be

Colorado patient safety advocate Patty Skolnik named to AHRQ council Patty Skolnik, founder and executive director of Citizens for Patient Safety, has been appointed to serve on the National Advisory Council for Healthcare Research and Quality of the Agency for Healthcare Research and Quality. Skolnik is a leading voice in Colorado for patient safety. Her term extends through November 2016.

CMS .ORG CMS ORG CMS.ORG CMS ORG Colorado Medical Society

This council makes recommendations to AHRQ’s director and to the secretary of the Department of Health and Human Services on priorities for a national health services research agenda. The 21-member panel is comprised of private-sector experts who contribute a varied perspective on the health care system and the most important questions that AHRQ’s research should address to promote improvements in the quality, outcomes and cost-effectiveness of clinical practice. The private-sector members represent health care plans, providers, purchasers, consumers and researchers. Ex-officio members include representatives of seven federal agencies that address health system issues. n

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increased and no longer budget neutral, and the phase-in of penalty risks for those who fall in the lowest performance quartile would be capped at a maximum of 9 percent (as opposed to the previous 12 percent). • The 5 percent added incentive payment for physicians in Alternative Payment Models was retained. • Funding for technical assistance to small practices of 15 or fewer professionals was doubled. • Provisions similar to the Standards of Care Protection Act were included. • Physicians who opt out of Medicare to engage in private contracting with their patients would no longer be required to renew their opt-out status every two years. AMA President Ardis Dee Hoven, MD, sent a letter and e-mail to physicians in late February urging their action. “This decade-long cycle of temporary patches to prevent steep payment cuts must end,” she said. This process “has cost more than $150 billion to date. That’s more than the cost of eliminating this failed policy. Clearly, repealing the SGR is the fiscally responsible way toward a higher performing Medicare program. Don’t let Congress resort to yet another patch or, even worse, a 24 percent cut to physician payments.” Send an email to Congress now through FixMedicareNow.org or call lawmakers through the AMA’s Physicians Grassroots Network hotline at (800) 8336354. It’s time to repeal the SGR by passing HR 4015/S 2000. n

Colorado Medicine for March/April 2014


Departments

medical news New report focuses on consumer engagement and health care The Colorado Health Institute recently released the first in a series of reports that focus on market-based solutions to help improve the quality and efficiency of the health care system. “Sharing the Cost: A Changing Landscape” looks at the increasing use of consumer costsharing in the health insurance market. The report provides a broad understanding of the theory and goals of costsharing, which includes health insurance plans with higher deductibles or higher co-pays; examines the evidence of its ability to curb costs; and looks at whether cost-sharing impacts the use of

health care and, ultimately, health outcomes. The authors report that increasing the level of cost-sharing can contribute to the slowdown in the growth of health care. However, increasing the level of cost-sharing leads to less use of medical care, especially when increased costsharing is first implemented; results in some people cutting back on all medical services, including care that may be covered by their insurance or care that is needed to maintain their health; motivates some people to select less-costly options, such as generic drugs; contrib-

utes to worse health for some low-income people who are already sick; and fails to curb the highest users of medical care who continue to use the most services, even with cost-sharing. The goal of the full series – “Consumer Engagement and the Health Care System” – is to analyze efforts to improve the quality and efficiency of the health care system through the lens of marketbased solutions. The reports will analyze whether more informed and more engaged consumers can help bend the health care cost curve while improving overall health. n

SAMHSA warns of increased deaths linked to fentanyl-contaminated heroin Health Services Administration (SAMHSA) is alerting physicians, treatment providers and the general public of an increase in deaths reportedly linked to the use of heroin contaminated with the drug fentanyl. Fentanyl is a form of opioid and when used in combination with heroin can rapidly cause severe injury and even death. There have been more than 17 deaths linked to the possible use of fentanylcontaminated heroin in the Pittsburgh, Pa. area alone since Jan. 24, 2014. In the first two weeks of January there were 22 such deaths reported in Rhode Island. It has been observed that these trends can expand quickly to include large and more distant geographic areas of the country. Additional deaths have been reported in New Jersey and Vermont. SAMHSA requests treatment providers alert their patients and greater community stakeholders to be on alert to the increased risk of fatal overdose. Colorado Medicine for March/April 2014

SAMHSA released an Opioid Overdose Toolkit late last year that contains information on recognizing and responding appropriately to overdose in a manner suitable to a variety of stakeholders. Go to www.store.samhsa.gov/product/ SMA13-4742 to view or download the free toolkit. Physicians and other treatment providers are engaged in providing the most effective form of overdose prevention: medication-assisted treatment. Achieving recovery remains the best method for preventing fatal overdoses and other risks. Those seeking treatment for opioid dependence can find help through SAMHSA’s Treatment Locator at 800-662HELP (4357) or online at www.samhsa. gov/treatment. For more information, contact Melinda Campopiano, MD, at (240) 276-2701 or melinda.campopiano@samhsa.hhs.gov. n

Encourage a colleague to join the Colorado Medical Society and your local medical society today! Visit www.cms.org to learn more about the benefits of becoming a member For more information and an application to join, call Tim Yanetta at

720-858-6306 or e-mail tim_yanetta@cms.org

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Departments

medical news FDA warns physicians against purchasing pharmaceuticals from foreign or unlicensed suppliers Over the last few months, the FDA has sent notices to physicians across the country, including Colorado, warning them about the illegality of purchasing pharmaceuticals from foreign or unlicensed suppliers, some of whom even have detailers and all the collateral materials to create the illusion of legality and respectability.

location, formulation, source specifications of active ingredients, processing methods, container-closure systems and appearance. A product imported into the United States that is unapproved for U.S. sale or does not comply with U.S. labeling requirements is prohibited according to federal law. Many states have comparable statutes to the FDA.

Physicians who purchase from these unlicensed and foreign sources not only trigger an FDA investigation, they also draw the attention of the state medical and pharmacy boards since those purchases of illegally imported drugs also violate state statutes governing pharmaceuticals and medical practice.

Even if drugs sold outside of the U.S. are manufactured by the same company that makes the product for the U.S. market, the version produced for foreign markets is typically not branded for sale in this country since the foreign version lacks information required by federal law. These drugs are often labeled in a foreign language, making it difficult for patients t patient use that should be read prior to the patient receiving the product. If the product is imported or of

FDA approvals are manufacturer and product specific and include an array of requirements regarding manufacturing

Michael Volz, MD, announces decision to run for 2014-15 CMS president-elect Michael Volz, MD, an allergy/immunology physician in Greenwood Village, has announced his intention to run for president-elect of the Colorado Medical Society. The election will take place at the 2014 Annual Meeting in September. Volz has served medicine in many capacities over his more than 30year career including on the Clear Creek Valley Medical Society Board of Trustees and the American Lung Association of Colorado Board of Directors; as president of the Colorado Allergy and Asthma Society and CCVMS; and on numerous CMS committees. He currently chairs the

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CMS Constitution and Bylaws Committee and just completed a six-year tour of duty on the CMS Board of Directors. “Medicine’s many challenges change with time and demand attention by CMS and its experienced leaders,” he wrote in a statement of intent. “I believe I have the necessary qualities to serve as your next president-elect and ask for your thoughtful support.” CMS is accepting additional nominations for all leadership positions now. Nominate yourself or a colleague by contacting Dean Holzkamp at dean_ holzkamp@cms.org or 303-748-6113. n

unknown origin, the patient is far less likely to have information critical to their care. It is also fraudulent for prescribers who prescribe, dispense or administer illegally imported drugs to file for reimbursement. Moreover, if the product caused any injury, the prescriber could be exposed to malpractice liability without support from the manufacturer. To compound those infractions, the sale of misbranded and mislabeled drugs could trigger unfair and deceptive business practice claims under federal and state law, which carries a treble damages penalty. The health risks are self-evident: Those products are often of unknown origin, dubious quality and improperly labeled. There are no assurances that the product has been stored properly, which can be hypersensitive to temperature fluctuations and other environmental conditions. There is also no assurance the product isn’t counterfeit or that it actually contains the appropriate active ingredient; products of unknown origin could contain toxic or inactive ingredients. Like street knockoffs of high-end watches, handbags or jewelry, physicians should intuitively know that with that kind of pricing, there’s a high probability it’s not the real thing. And there is a higher price to pay when the knockoff is a non-FDA approved prescription drug. Physicians getting solicited to purchase drugs can readily verify their legality through the FDA website: tinyurl.com/ fda-verify as well as the state board of pharmacy: tinyurl.com/dora-pharmacy. n Colorado Medicine for March/April 2014


Departments

classified advertising Publication of any advertisement in Colorado Medicine is not an endorsement by the Colorado Medical Society of the product or service. Colorado Medicine magazine is the official journal of the Colorado Medical Society and is authorized to carry general advertising.

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Seeking Primary Care Physicians/Practices in the Denver Metro Area We are seeking quality physicians to join our existing Englewood clinic OR Physicians/Practices that could add to our geographic coverage of the metropolitan area. If you are a physician or group that would like to: • Join a group with a fully integrated Electronic Health Record, • Be a part of an NCQA Recognized Level 3 Medical Home, and • Make a change but maintain your current patients We can offer a unique opportunity to get back to treating patients and stop worrying about administrative and personnel headaches. We are not a broker and will not respond to broker inquiries. If interested, contact Janelle at (303) 493-5276. All inquiries will be kept in strict confidence and will receive a prompt response.

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Join Now! Colorado Medical Political Action Committee Call 720-858-6327 or 800-654-5653, ext. 6327 or e-mail susan_koontz@cms.org

Colorado Medicine for March/April 2014

Please help support CMSF In March 1997, Colorado Medical Society established the Colorado Medical Society Foundation (CMSF) as a 501(c) 3 organization. The foundation’s mission is to administer and financially manage programs that seek to improve access to health care and health services, with the potential to improve the health of Coloradans. The Board of Trustees of CMSF is committed to the success of these programs and excited about the possibilities they present for improving health care services in Colorado. The spirit of Colorado is alive in the many ways that we help our neighbors. Call 720-858-6310 for more information and to donate. 45


Features

the final word Alan Kimura, MD, MPH

Making cost-effective choices because it's the right thing to do Viewed from a high-level perspective, U.S. health care reform continues its amazing, century-long journey. In 2014 the Affordable Care Act is attempting to reduce the ranks of uninsured Americans and experiment with new models of health care delivery. However, health care financing remains vexingly fragmented in its incentives. If physicians (who control 80 percent of spending by their ordering, yet receive only 15 percent of spending for their services) were rewarded for value not volume, then billions of dollars could be saved each year within the system. Stewardship in action Reflecting on Maslow’s Hierarchy of Needs, it is no wonder that some providers find the practice of stewardship merely aspirational, rather than routine. That begs a question: Could stewardship be incentivized to drive system savings? Or more simply put, why is it so difficult to do the right thing in health care? These are complex questions, but my practice is proof that effort is being made by Colorado physicians and savings are possible. I work with 10 like-minded physicians in a single-specialty, private group, practicing in five offices throughout the Front Range. As ophthalmic vitreoretinal specialists, we must choose between equivalently efficacious biologic drugs, but with strikingly different costs on a daily basis. We routinely treat macular degeneration with the drug Avastin. Avastin is an FDA-approved cancer medication that also is commonly repackaged and used off-label by retina specialists for the treatment of macular degeneration. Avastin is widely used because it is a highly effective treatment and it is substantially less expensive (approximately $64 per injec 46

tion) than the other approved alternative Lucentis (approximately $1,980 per injection).(1) Our practice uses the lesscostly drug 70 percent of the time, and the more-costly drug 30 percent of the time, after patients fail treatment with the cheaper drug. Last year our practice did approximately 16,000 injections and by using the less costly drug we saved the system $21.4 million. Interestingly, some practices nationwide are inverted in their prescribing practices, deploying the more expensive drug more of the time. How can these disparities be justified? Stewardship, according to Richard Block, is a contrarian reframing of a resource problem from one of scarcity to one of abundance. Economics has come to dominate virtually all sectors of life, including health care, and its fundamental tenet is that resources are finite. This mindset drives success in business, which in turn fuels beneficial innovation. But at the same time, scarcity creates pervasive anxiety. Rare is the discussion amongst current health care providers of a sense of security; it’s quite the opposite, of course. Every licensed physician retains the autonomy to prescribe as he or she sees fit for the patient. Perhaps they find security against malpractice risks when using the more expensive, FDA-approved, manufactured drug. Others are compelled to use the expensive drugs because they are available off the shelf; in some states, the requirement for “patient-specific prescriptions” of compounded drugs force patients to return for another injection visit. Likely the imperative for economic self-interest, which any rational business would practice, is driving physicianprescribing behavior under current feefor-service payment. We didn’t reap any benefits from using more Avastin versus Lucentis. In fact we lost money because a

small, slightly greater margin is retained when prescribing the more costly drug based on average sales price. Make it easier So why does our practice continue its Sisyphean stewardship of pushing the rock up the steep economic hill? Speaking for my partners, we simply feel it is the right thing to do, to transcend maximizing profit for no benefit to our patients. There is no doubt that our stewardship struggles against misaligned incentives in our highly fragmented health care system. The fact is that transcendent, selfactualization alone is unlikely to transform the $2.6 trillion annual U.S. health care expenditure. Even well meaning stewards must acknowledge the reality that if there is no margin, they cannot perform their mission. Let’s face it, $21.4 million in savings is a small start. But then again we are just one practice. More can be done if changes are made. Harold Miller and others argue that physicians should be properly incentivized to make cost-effective decisions and be rewarded as the key professionals in the health care system that can operationalize such system-wide transformation.(2) A higher level of perspective and ultimately greater alignment of agendas between fragmented stakeholders should be explored. n Endnotes: (1) Martin, D. F., M. G. Maguire, S. L. Fine, G. S. Ying, G. J. Jaffe, J. E. Grunwald, C. Toth, M. Redford, F. L. Ferris and C. o. A.-r. M. D. T. T. C. R. Group (2012). "Ranibizumab and bevacizumab for treatment of neovascular agerelated macular degeneration: two-year results." Ophthalmology 119(7): 1388-1398. (2) Miller, H. (2014). "Paying for the SGR Repeal." http://www.chqpr.org/downloads/Paying_for_SGR_Repeal.pdf.

Colorado Medicine for March/April 2014


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Colorado Medicine for March/April 2014


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